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Orthopaedic Surgery Clinical Privileges
1
Orthopaedic Surgery
Version: Final October 1, 2014
Name: _____________________________________________________
Effective from _______/_______/_______ to _______/_______/_______
❏ Initial privileges (initial appointment) ❏ Renewal of privileges (reappointment)
All new applicants should meet the following requirements as approved by the governing body,
effective: 15-MAR-2015.
Applicant: Check the “Requested” box for each privilege requested. Applicants are responsible
for producing required documentation for a proper evaluation of current skill, current clinical
activity, and other qualifications and for resolving any doubts related to qualifications for
requested privileges. Please provide this supporting information separately.
[Department/Program Head or Leaders/ Chief]: Check the appropriate box for
recommendation on the last page of this form and include your recommendation for any
required evaluation. If recommended with conditions or not recommended, provide the
condition or explanation on the last page of this form.
Current experience is an estimate of the level of activity below which a collegial discussion
about support should be triggered. It is not a disqualifier. This discussion should be guided not
only by the expectations and standards outlined in the dictionary but also by the risks inherent
in the privilege being discussed and by similar activities that contribute to the skill under
consideration. This is an opportunity to reflect with a respected colleague on one's professional
practice and to deliberately plan an approach to skills maintenance.
Other requirements
• Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have
sufficient space, equipment, staffing, and other resources required to support the privilege.
• This document is focused on defining qualifications related to competency to exercise
clinical privileges. The applicant must also adhere to any additional organizational,
regulatory, or accreditation requirements that the organization is obligated to meet.
Note: The dictionary will be reviewed over time to ensure it is reflective of current practices,
procedures and technologies.
Grandparenting: Practitioners holding privileges prior to implementation of the dictionary will continue to hold those privileges as long as they meet current experience and quality requirements.
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Definition
The responsibility of the Orthopaedic Surgeon is to assess and treat conditions affecting the musculoskeletal system with the goals of relieving pain and maintaining or improving function
Qualifications for Orthopaedic Surgery
Initial privileges: To be eligible to apply for privileges in Orthopaedic surgery, the applicant
should meet the following criteria:
Be currently certified as an Orthopaedic Surgeon by the Royal College of Physicians and
Surgeons of Canada (RCPSC)
AND/OR
Be recognized as an Orthopaedic Surgeon by the College of Physicians and Surgeons of British
Columbia (CPSBC) by virtue of credentials that are acceptable to both the CPSBC and the
governing body of (Health Authority).
AND
Recommended current experience: At least 84 booked surgical hours a year as the primary
surgeon averaged over the past 24 months, reflective of the scope of privileges requested, OR
successful completion of a residency or clinical fellowship within the past 12 months. The
department head will have the authority to override these standards through a similar process
as outlined in the return to practice section.
Physicians employing fluoroscopic techniques during procedures will have a current radiation
safety course.
Renewal of privileges: To be eligible to renew privileges in orthopaedic surgery, the applicant
should normally meet the following criteria:
Successful participation in the Royal College of Physicians and Surgeons Maintenance of
Certification Program
Current demonstrated skill and sufficient experience (84 booked surgical hours a year as the
primary surgeon averaged over the past 36 months), reflective of the scope of privileges
requested, based on successful ongoing professional practice evaluation.
Physicians employing fluoroscopic techniques during procedures will have a current
radiation safety course.
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Return to practice: As a minimum, evaluation by a colleague who holds core privileges in Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill.
Core privileges: Orthopaedic Surgery Core privileges are offered to ALL members in the discipline as long as the facility can support
those activities.
❑ Requested Provide consultation and manage patients with orthopaedic conditions a. May
provide care to patients in the intensive care setting in conformance with unit policies. ssess,
stabilize, and determine the disposition of patients with emergent conditions consistent with
medical staff policy regarding emergency and consultative call services. The core privileges in
this specialty include the procedures on the attached procedures list and such other procedures
that are extensions of the same techniques and skills.
Core procedures list
This is not intended to be an all-encompassing procedures list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this
organization and inherent activities/procedures/privileges requiring similar skill sets and
techniques.
To the applicant: If there is a procedure you wish to NOT perform, then please type into the
Comments field.
Trauma including multisystem trauma excluding complex pelvic fractures
Routine hand and wrist surgery
Routine foot and ankle surgery
Surgery for Athletic injuries, including arthroscopy
Amputations excluding girdle amputations (forequarter and hindquarter amputations)
Orthopaedic oncology excluding limb salvage for primary malignant disease except under
the direction of an orthopaedic oncologist
Joint aspiration/injection
Casting and splinting
Wound management
Management of bone, joint and soft tissue infection
Primary/uncomplicated hip and knee replacement (including revision of modular
components)
Routine shoulder/elbow surgery (including shoulder hemiarthroplasty and radial head
replacement for trauma)
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Non-core Privileges (See Specific Criteria)
Non-core privileges may be requested for by individuals who have further training,
experience and demonstrated skill.
Non-core privileges are requested individually in addition to requesting the core.
Each individual requesting non-core privileges should meet the specific threshold criteria
as outlined.
Non-core privileges: Spine procedures ❑ Requested
Initial privileges: Fellowship in adult and/or pediatric spine surgery or documentation of
additional training or experience
AND
Recommended current experience: At least 20 spine procedures per year averaged over the
past 24 months, OR successful completion of a clinical fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 spine
procedures per year, averaged over the past 36 months), reflective of the scope of privileges
requested, based on successful ongoing professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill.
Non-core privileges: Complex primary hip and knee arthroplasty and revision hip and knee arthroplasty ❑Requested
Initial privileges: Fellowship in adult reconstructive orthopaedics or documentation of
additional training or experience
AND
Recommended current experience: At least 10 complex primary hip and knee arthroplasty/or
revision hip and knee arthroplasty procedures per year averaged over the past 24 months, OR
successful completion of a clinical fellowship within the past 12 months.
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 complex
primary hip and knee arthroplasty and revision hip and knee arthroplasty procedures per year
averaged over the past 36 months), reflective of the scope of privileges requested, based on
successful ongoing professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Non-routine trauma including pelvic or acetabular fractures and complex malunion/nonunion/deformity reconstruction ❑Requested
Initial privileges: Fellowship in orthopaedic trauma or documentation of additional training or
experience
AND
Recommended current experience: At least 10 non-routine trauma procedures per year
(including pelvic or acetabular fractures and complex malunion/nonunion/deformity
reconstruction) averaged over the past 24 months, OR successful completion of a clinical
fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 non-
routine trauma procedures per year - including pelvic or acetabular fractures and complex
malunion/nonunion/deformity reconstruction – averaged over the past 36 months), reflective of
the scope of privileges requested, based on successful ongoing professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Limb salvage surgery for primary malignant bone neoplasia ❑ Requested
Initial privileges: Fellowship in musculoskeletal oncology or documentation of additional
training or experience
AND
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Recommended current experience: At least 10 limb salvage surgeries per year for primary
malignant bone or soft tissue neoplasia over the past 24 months, OR successful completion of a
clinical fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 limb
salvage surgeries per year for primary malignant bone or soft tissue neoplasia, over the past 36
months), reflective of the scope of privileges requested, based on successful ongoing
professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Non-routine hand and wrist surgery including arthroplasty and arthroscopy ❑ Requested
Initial privileges: Fellowship in hand and wrist surgery or documentation of additional training
or experience
AND
Recommended current experience: At least 10 non-routine hand and wrist surgeries per year
(including arthroplasty and arthroscopy) over the past 24 months, OR successful completion of a
clinical fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 non-
routine hand and wrist surgeries per year - including arthroplasty and arthroscopy - over the
past 36 months), reflective of the scope of privileges requested, based on successful ongoing
professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Microvascular surgery including re-implantation and microvascular flaps
❑ Requested
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Initial privileges: Fellowship in hand and wrist surgery (including microvascualr surgery) or
documentation of additional training or experience
AND
Recommended current experience: At least 5 microvascular surgeries per year (including re-
implantation and microvascular flaps) over the past 24 months, OR successful completion of a
clinical fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 5
microvascular surgeries per year - including re-implantation and microvascular flaps - over the
past 36 months), reflective of the scope of privileges requested, based on successful ongoing
professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Non-routine foot and ankle surgery including joint arthroplasty and complex deformity reconstruction
❑ Requested
Initial privileges: Fellowship in foot and ankle surgery or documentation of additional training or
experience
AND
Recommended current experience: At least 10 non-routine foot and ankle surgeries per year
(including joint arthroplasty) over the past 24 months, OR successful completion of a clinical
fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 non-
routine foot and ankle surgeries per year - including replacement - over the past 36 months),
reflective of the scope of privileges requested, based on successful ongoing professional practice
evaluation.
Return to practice: As As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Non-core privileges: Non-routine shoulder and elbow surgery, including arthroscopy and total joint arthroplasty
❑ Requested
Initial privileges: Fellowship in shoulder and elbow surgery or documentation of additional
training or experience
AND
Recommended current experience: At least 10 non-routine shoulder or elbow surgeries per
year (including arthroscopy and total joint arthroplasty) over the past 24 months, OR successful
completion of a clinical fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 non-
routine shoulder or elbow surgeries per year - including arthroscopy and total replacement -
over the past 36 months), reflective of the scope of privileges requested, based on successful
ongoing professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Non-routine paediatric orthopaedics (patients under 18 years of age)
❑ Requested
Initial privileges: Fellowship in paediatric orthopaedics or additional training or experience
AND
Recommended current experience: At least 10 paediatric orthopaedic procedural cases per
year, averaged over the past 24 months reflective of the scope of privileges requested, OR
successful completion of a clinical fellowship within the past 12 months.
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10
paediatric orthopaedic surgical and non-surgical cases per year, averaged over the past 36
months), reflective of the scope of privileges requested, based on successful ongoing
professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Non-core privileges: Osteotomy and non-routine arthroscopic surgery of the hip and knee
❑ Requested
Initial privileges: Fellowship in advanced arthroscopic techniques or additional training or
experience
AND
Recommended current experience: At least 10 non-routine arthroscopic and joint preservation
surgeries per year, averaged over the past 24 months, OR successful completion of a clinical
fellowship within the past 12 months.
Renewal of privileges: Current demonstrated skill and sufficient experience (at least 10 non-
routine arthroscopic and joint preservation surgeries per year, averaged over the past 36
months), reflective of the scope of privileges requested, based on successful ongoing
professional practice evaluation.
Return to practice: As a minimum, evaluation by a colleague who holds these privileges in
Orthopaedic Surgery for a period of time sufficient for the mentor to attest to skill
Context Specific Privileges
Context refers to the capacity of a facility to support an activity
Administration of procedural sedation and analgesia
❑ Requested
See “Hospital Policy for Sedation and Analgesia by Non-anesthesiologists.”
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
Process for requesting privileges not included in the dictionary
Where a member of the medical staff requests a privilege not included in the core, non-core or context specific privileges for a discipline, the following process will be followed.
1. The practitioner will submit a request in writing to the head of department or chief of staff identifying the privilege requested, the location within the facility where the privilege would be exercised, and the relevant training and experience held by the practitioner in this area.
2. The department head or chief of staff will consult with the credentialing office and the senior medical administrator responsible for the facility to determine if this request is reasonable
3. If it’s determined that the request is reasonable, the senior medical administrator will consult his or her administrative counterpart to determine if the facility can support the activity.
4. Where it is deemed appropriate, the practitioner, the department head or chief of staff and the senior medical administrator will agree on any additional training required, and a minimum level of activity required to maintain the privilege. The specific minimum number requirement indicating the level of experience required to demonstrate skill to obtain clinical privileges for the requested procedure must be evidence-based, and where no supporting literature exists for a specific number, the criteria are established by the consensus of a multidisciplinary group of practitioners who do not have a self-interest in creating an artificially high volume requirement.
5. Before proceeding with training the request will be reviewed by the Central Coordinating Office or its successor.
6. Any additional training will be done in a facility that normally trains practitioners in this activity. Exceptions may be granted in circumstances where all that is required is training by a member of the medical staff who holds the privilege in question.
7. On satisfactory completion of training, the department head or chief of staff may recommend to the governing body through the medical advisory committee that the privilege be granted.
Acknowledgment of Practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at [facility
name], and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff
policies and rules applicable generally and any applicable to the particular situation.
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation,
and in such situation my actions are governed by the applicable section of the medical staff
bylaws or related documents.
Signed: ________________________________________ Date: _____________________
[Department/Program Head or Leaders/Chief]’s Recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-
named applicant and:
❑ Recommend all requested privileges
❑ Recommend privileges with the following conditions/modifications:
❑ Do not recommend the following requested privileges:
Privilege Condition/modification/explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
______
______________________________________________________________________________
______
______________________________________________________________________________
______
[Department/Program Head or Leaders/ Chief] Signature:
______________________________
______
Date:
______________________________
______
FOR MEDICAL AFFAIRS USE ONLY (Tailor to Health Authority Process)
Credentials committee action Date: ________________________
Medical executive committee action Date: ________________________
Board action Date: ________________________
Orthopaedic Surgery Clinical Privileges
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Orthopaedic Surgery
Version: Final October 1, 2014